Nobody Made Anyone Substantiate the “Yes”

The post: Joe, a healthcare attorney, wrote that a 'not medically necessary' denial is the payer's determination, not proof, and listed five questions physicians should ask before accepting one, ending with: why shouldn't payers have to substantiate their denials?

Read Joe Rivet's original post on LinkedIn →

My comment:

Joe — your question #5 cuts both ways, and the second direction almost never gets asked.

For ten years nobody asked me any of these. My claims were paid. Clean, fast, no questions. Facet injections twelve times a year when the guideline is four. Paid. Home health on a man who rode his bike to the grocery store. Paid.

A denial isn't evidence a service was unnecessary. But a payment was never evidence it was necessary either. Mine proved only that nobody had scrutinized them yet.

You're asking payers to substantiate a "no." Nobody ever made anyone substantiate the "yes." That's the part I lived on.

Originally posted as a comment on LinkedIn.